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        <p>北京协和医院口腔科周炼医生分享<br>坚果学院的免费课<br>一、概述<br>拔牙前准备:询问病史，影像学检查，知情同意。<br>调整体位:咬合平面位置:与肘部平齐;咬合平面角度:大张口时下颌平面与地面平行。<br>准备器械<br>局麻<br>拔除<br>二、下颌阻生智齿的分类<br>角度:智齿牙长轴与邻牙关系，垂直，近中，远中，水平，倒置，颊向，舌向。<br>垂直位置:阻生牙最高点与第二磨牙位置关系。高位，中位，低位。<br>颊舌位置:颊向，舌向。<br>三、难度分析<br>年龄因素:越大越难拔。<br>性别因素:男性大于女性。<br>牙根形态:数量，弯曲角度，全景片上单根的智齿未必拔牙难度小，有的是融合根，根粗大等。<br>角度因素:垂直阻生相对难度小，其余情况难度大。<br>位置因素:位置越高，难度越小。<br>炎症因素:急性期刚过拔智齿难度会下降。<br>关节因素:有关节疾病的患者不能大张口或长时间大张口，影响操作。<br>心理因素:<br>下牙槽神经与牙根关系阻生智齿的钙化，晚于下颌管，而下颌管周围有骨皮质。理论上牙根的发育很难真的突破下颌管骨皮质进入下颌管。往往是透射角度的问题。临床上下颌管的损伤往往发生在断根后掏根的过程中。在判断牙根与下颌管关系时不要过度，尽量不要断根，如接近下颌管的牙根折断，与患者沟通，权衡利弊风险考虑是否取出断根。<br>四、常用器械<br>仰角手机:国产进口无本质差别<br>拔牙车针:若不想换车针可用金刚砂钻，工作长度较长。但其尖端易磨耗，工作效率降低。<br>五、麻醉方法<br>下牙齿神经阻滞麻醉<br>部位:翼下颌韧带稍外侧。颊脂垫尖与翼下颌韧带之间。技巧，用口镜寻找下颌升支前缘，在其后2cm处进针。<br>一进针就碰到骨面，原因是碰到下颌骨升支内侧隆起。退一下，注射点靠后，角度偏大，绕过隆起。<br>局部麻醉<br>配合碧兰麻。颊侧近中、远中、舌侧。<br>六、下颌阻生智齿拔除的技术详解<br>1.近中阻生智齿<br>阻力分析:邻牙阻力，骨阻力，软组织阻力。<br>切开粘骨膜:从7颊侧斜行切口至龈沟，再延伸至8远中。如完全埋伏，沿8牙槽嵴顶切开。(也有老师建议先做水平切口，翻瓣后暴露不够再做7的垂直切口，因为垂直切口易引起肿胀。<br>翻开粘骨膜瓣，暴露骨面。<br>去除部分骨暴露牙冠(暴露牙冠最大周径即可)<br>拔牙手机去除部分近中牙冠:一般用金刚砂钻，角度与7牙长轴平行。不要去除过多或过少。去除过大，去除的半冠难以取出(可再做T型分牙)。常见错误:①角度错误:要与7牙长轴平行;②分冠过于靠后，去除的半冠难以取出。<br>用牙挺挺出智齿。放挺位置，近中轴角或颊侧。颊侧、远中骨板较厚，舌侧骨板较薄。最适合位置，近中颊侧轴角。近中颊根根尖向远中弯曲，如此挺牙根阻力较小。从颊侧挺出效率不高。有的牙根较粗大，近中轴角和颊侧均可用力。<br>牙根分叉较大的可分根拔除。分根前根据X片设计好分根角度。<br>2.远中阻生智齿拔除<br>切龈翻瓣去骨同前。<br>如骨阻力较大，只去骨去骨量较大，可远中分冠。<br>3.阻生智齿的挺出<br>牙根与牙槽骨并不是骨性固连，其间有牙周膜连接。拔除时要将牙周膜完全撕断。通过牙挺或牙钳晃动，由轻到重使牙周膜断裂。如牙槽骨与牙根包绕紧密甚至有倒凹，不一定会断根。牙根移动的过程中牙槽骨有可让性，会压缩。<br>弯曲的牙根，有可能断折。根据情况判断是否取出。<br>七、微创意识<br>并不取决于”微创器械”，主要是微创意识:贯穿始终的爱伤意识，利用合适工具，把创伤减少到最小。<br>设计巧妙，操作精准，力量轻柔。<br>粘膜:切开翻瓣，精确复位并缝合，避免撕裂。<br>牙槽骨:尽量少磨骨，避免舌侧骨板折断，骨板折断需要复位。<br>牙齿:不能伤及邻牙及对颌牙，利用高速钻取出阻力。<br>拔牙窝:缝合，止血。<br>器械使用:磨钻，拔牙钳，拔牙挺。</p>
<p>谢谢周医生分享!</p>
<p>我发文章的四个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的博客园博客地址： <a target="_blank" rel="noopener" href="https://www.cnblogs.com/zwdnet/">https://www.cnblogs.com/zwdnet/</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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